Peptic ulcer disease in patients with end-stage chronic kidney disease presents a complex clinical problem due to metabolic disturbances, impaired mucosal regeneration, polypharmacy, and limitations in the use of standard medications. In this study, we conducted a comparative analysis of conservative and surgical (kidney transplant) management of gastric and duodenal ulcers in patients with end-stage renal disease versus patients without renal dysfunction. Among the 34 patients who were examined, findings showed that kidney transplant contributed to rapid ulcer healing, normalization of biochemical parameters, and reduction in recurrence rates. The study highlighted the necessity of individualized treatment strategies for patients with end-stage renal disease and emphasized the importance of restoring renal function to improve gastrointestinal outcomes. Key words: ESRD, Gastrointestinal bleeding, Hemodialysis, Kidney transplantation, Mucosal healing, Peptic ulcer disease, Recurrence

Introduction
Peptic ulcer disease remains a major health concern worldwide, affecting millions of individuals each year.¹ Although its etiology is often associated with Helicobacter pylori infection, nonsteroidal anti-inflammatory drugs use, and stress-related mucosal damage,² the presence of end-stage chronic kidney disease (ESRD) significantly alters the natural course and management of the condition.³ Patients with ESRD experience a wide spectrum of systemic metabolic abnormalities, such as uremia, secondary hyperparathyroidism, fluid-electrolyte imbalance, and impaired drug clearance.⁴ These pathophysiological changes negatively affect gastrointestinal function, reduce mucosal defense, and increase susceptibility to ulcer formation and complications.⁵ Furthermore, long-term hemodialysis introduces additional stressors, including repeated anticoagulation, fluctuations in blood pressure, and reduced gastric perfusion.⁶ As a result, patients with ESRD exhibit higher rates of bleeding, recurrence, perforation, and treatment-resistant ulcers compared with the general population.⁷ Kidney transplantation, as the definitive treatment for ESRD, dramatically improves metabolic homeostasis and may influence both the progression and healing of peptic ulcers.⁸ However, the extent of this improvement and its relationship to conservative therapy remain insufficiently studied. In this study, we aimed to deepen the understanding of ulcer management in ESRD and clarify the role of kidney transplant in improving clinical outcomes. For this analyses, we evaluated the efficacy of conservative therapy and surgical intervention (kidney transplant) in the treatment of peptic ulcers among ESRD patients undergoing hemodialysis and compared the results with patients who did not have significant renal impairment.

Materials and Methods
We included 34 adult patients diagnosed with gastric or duodenal peptic ulcers. Among the study group, 22 patients (65%) had ESRD and were receiving regular hemodialysis. Their age ranged from 35 to 56 years, with an average age of 44.11 years; 16 were men (73%) and 6 were women (27%). The duration of hemodialysis varied from 5 to 36 months (mean duration of 14.54 months). Twelve patients (35%) without ESRD served as a comparison group and received standard anti-ulcer therapy according to established clinical guidelines. Patients with ESRD were treated with a tailored therapeutic regimen consisting of bismuth, metronidazole, and pantoprazole, chosen due to safety profiles suitable for renal impairment. Subsequently, the 22 patients in the ESRD group underwent kidney transplant from living related donors, including siblings (n = 6, 27%), parents (n = 5, 23%), uncles/aunts (n = 4, 18%), and spouses (n = 7, 32%). The remaining 12 patients with normal renal function served as the control group. We assessed the follow clinical outcomes: time to ulcer healing and endoscopic confirmation of scarring, frequency of ulcer complications (bleeding, perforation, recurrence), pre- and postoperative creatinine levels, and treatment efficacy in ESRD compared with non-ESRD patients. Endoscopic assessments were performed at enrollment and at scheduled intervals posttransplant.

Results

Ulcer healing and clinical outcomes
Among 22 patients with ESRD, 20 (91%) achieved complete ulcer scarring within 3 months (Figure 1). This finding represented a significant acceleration compared with the pretransplant period, during which recurrent or persistent ulceration was common. Pretransplant endoscopic findings in ESRD patients included the following: active ulceration in 16 patients (73%) (Figure 2), recurrence or exacerbation in 13 patients (59%) (Figure 3), and upper gastrointestinal bleeding in 3 patients (14%) (Figure 4). In contrast, the non-ESRD group demonstrated stable healing under standard therapy with no major complications (Figure 5). Pretransplant findings are summarized in Figure 6.

Biochemical improvements
A notable decline in serum creatinine levels was observed after transplant. The preoperative creatinine range of 0.5 to 0.87 mmol/L decreased to 0.056 to 0.12 mmol/L in the postoperative period (mean 0.08 mmol/L) (Figure 7). This biochemical normalization correlated strongly with the observed improvements in ulcer healing and reduction of associated symptoms.

Therapeutic effectiveness
The combination of bismuth, metronidazole, and pantoprazole was shown to be effective in patients with ESRD; however, complete remission was rarely achieved before transplant due to persistent metabolic disturbances. Posttransplant immunosuppressive therapy (tacrolimus, corticosteroids) did not impede ulcer healing. Instead, the improved systemic condition and restored renal function significantly enhanced reparative processes in the gastrointestinal mucosa.

Discussion
The results of this study underscored the profound effects of renal function on the course and management of peptic ulcer disease.⁹ Uremic toxins, metabolic acidosis, electrolyte shifts, and chronic inflammation collectively impair gastric mucosal integrity.¹⁰ These factors also limited the therapeutic effectiveness of standard anti-ulcer medications in patients with ESRD.¹¹ The higher prevalence of bleeding and recurrence observed in the ESRD group confirmed the vulnerability of this population and the need for carefully adjusted treatment strategies.¹² Kidney transplant plays a pivotal role by restoring metabolic stability, improving vascular perfusion, and enhancing tissue regeneration.^13,14 The rapid ulcer healing observed after transplant suggested that renal recovery, rather than anti-ulcer therapy alone, is the determinant factor in resolving chronic mucosal damage in ESRD patients.¹⁵ These findings highlight the necessity for a multidisciplinary approach involving nephrologists, gastroenterologists, and transplant surgeons to achieve optimal outcomes.¹⁶

Conclusions
Peptic ulcer disease in patients with ESRD is characterized by a more severe course, higher recurrence rates, and increased risk of complications compared with patients without renal impairment. Conservative therapy with bismuth, metronidazole, and pantoprazole, although safe and beneficial for ESRD patients, may not ensure complete healing due to persistent metabolic abnormalities. Kidney transplant accelerates ulcer healing, decreases recurrence rates, and normalizes biochemical markers, particularly serum creatinine. The restoration of renal function is a critical factor in resolving peptic ulcer pathology in ESRD patients and should be considered an integral component of long-term management. We suggest that a combined therapeutic strategy, encompassing conservative medical therapy, optimization of dialysis, and timely transplantation, offers the best outcomes for patients with ESRD and peptic ulcer disease.